This morning, I have the privilege of introducing both of our speakers. We'll beginning with Dr. Daniel Maxner. He's a clinical professor of psychiatry at the Michigan Medicine, University of Michigan Hospital. He has served as the ECT program director for over 25 years. He has clinical and research experience in ECT, transcranial magnetic stimulation, deep brain stimulation, and intravenous ketamine. He also currently serves as the vice president for the International Society of ECT and Neurostimulation. And our second speaker will be Dr. Leigh Wachtell. She is the medical director and an attending child psychiatrist of the neurobehavioral unit at the Kennedy Krieger Institute. She also directs the consult liaison services for the rehabilitation unit. She is a professor in the Department of Child and Adolescent Psychiatry at the Johns Hopkins University School of Medicine. You can please give both of them a warm welcome and round of applause, and Dr. Maxner will begin. Thank you. It's fantastic to be here in person, and I believe the clinical updates are also streaming, so it's a pleasure to work with everybody and do some updates on electroconvulsive therapy. Today's session, we're gonna be covering topics associated with ECT in adults, as well as ECT in pediatric patients. So no major disclosures here, some research funding from Janssen on a ketamine trial. And so this is what I'll be speaking to. We both, Dr. Wachtell and I, both have 30 minutes to cover. Each of us probably have 25 to 30 years of experience in ECT, so we're gonna try to cover as much as we can and give you some nice updates on topics and some updates from the literature as well. So I'm gonna, for the general audience here, I'm gonna cover a few ECT basics. We're gonna discuss ECT in the U.S., the use and access of ECT. Briefly, we'll cover some of the effects of COVID-19 and what happened to our clinical practice during that time, geriatric population and geriatric depression, depression with psychosis, maintenance ECT, a little bit about schizophrenia and ECT, bipolar disorder and ECT, and the topic of neuroleptic malignant syndrome, NMS, as a neuropsychiatric emergency and some of our experience there, and give you a taste of some studies and things that are going on right now in ECT versus ketamine. Okay, so here's just a few ECT basics for the general audience here. ECT is generating a brief seizure under anesthesia. The typical course is two to three times a week, six to 12 treatments is the typical range, but 12 is not a magic number, and we may need to go beyond that for a number of patients, especially patients who have been sick for a very long time. Outcomes for depression in general, this is a key take-home point, is that with depression and ECT, the thing that you really need to remember is that in our field, and the reason I do what I do is because ECT induces remission better than any treatment that's out there, essentially, and we're talking 60 to 80% remission. And what does that mean? What does that look like? Well, as many of us are aware, in drug studies and other depression studies, therapy studies, ECT studies, rating scales are used, and so we are taking our MADRS, our Montgomery-Osborn Depression Rating Scores, and Hamilton Rating Scores, and driving those scores all the way into single digits. That's different than, say, a typical drug trial, which is you're looking for a nice response, which can be 50% reduction of those scores. So we're always shooting for single-digit rating scores for our depression patients, and that's something to be mindful when you're reading the depression literature. Electroplacement is a key issue with ECT. We stimulate the brain using right unilateral or bilateral placement. There are some differences with memory that many of us are aware of, where right unilateral placement has less memory side effects. Bitemporal placement may be faster and may be reserved for patients who are very severely ill. I'm not gonna do a physics lecture for everybody, but this is just a brief graphic of what our machines spit out with respect to our ECT stimulation, and you'll see that on the left is a pulsatile type of stimulation. We're trying to activate brain neuronal tissue to fire up and have a brief seizure, and neurons, they depolarize, then they repolarize, and so we use a pulsatile type of stimulation versus older, what comes out of your outlet and what older machines would use from the 50s and 60s would have been more of a sine wave type of stimulation. The sine wave stimulation long ago, 40, 50 years ago, was also known to worsen memory side effects, so most of our machines have been using pulsatile type of stimulation, and the thing that's really taken place over the last 15 years especially is how those pulses are delivered, meaning that over time, there's been much research in using briefer and briefer pulses to activate the brain, and if you do that, you can essentially use more of an efficient stimulation and activate the brain using less electricity, less energy, and all of that can also cut down on memory side effects as well. So essentially since the 1990s and now in the 2000s, the brief pulse, the pulses have ranged from about one millisecond back in the 1990s, now all the way down to about 0.25 to 0.5 milliseconds. Okay, so here's a brief overview of when to consider using ECT. There are a number of worldwide organizations, including the APA, where there are guidelines to suggest when ECT is an appropriate treatment for patients, and here are some of the other ones from Canada, as well as Australia and New Zealand, and World Federation of Societies of Biologic Psychiatry. So you'll see here that for a number of these diagnoses, depression, ECT should be considered for depression as early as the first or second step when the illness is likely very severe. The APA guidelines suggest a third or fourth step. For other diagnoses, you'll see that it might be a little bit different, but in general, we're talking about for really severe psychiatric illness that ECT should be considered in that zone of third or fourth step, or even earlier if needed. So one condition, or one point that's made in our APA guidelines is that patient preference is important, and I talk about this with patients all the time. I talk about it when I'm teaching about ECT, is that patient preference should also be a part of the discussion. If you have a patient who's very sick, and they're lying on the couch, they're crying, they're suicidal, they haven't gone to their grandson's ball games, they haven't done anything for six to eight months, and they wanna die, and that patient says, you know, I've already tried two or three meds, and I really need to get out of this. This is dangerous. Well, I should take that into consideration for sure. And so that's one, again, that's an important factor when you're deciding to refer patients for ECT, and for us when we're recommending it. I was reminded today, too, that the APA ECT guidelines, we have a new set of guidelines that the organization should be publishing this year. So anyone that does practice ECT, or those interested in ECT should also check that out. Okay, so also with regards to ECT and cost-effectiveness, and this is, again, sort of thinking about when is ECT a smart thing to do? We did a study at Michigan where ECT was found to be cost-effective as early as after two or more failed medication trials. And so with cost-effectiveness analysis studies, you're doing some mathematical modeling and considering how this treatment would be appropriate from a cost and quality of life standpoint. And so again, in this particular model, we found that ECT is a reasonable option from a cost-effectiveness standpoint even after two medication failures. So how about use of ECT in the U.S.? So these numbers are really hard to come by and try to figure out. Because of our healthcare system in the U.S., we have multiple payers, we have various health systems, and it's quite often very difficult to estimate actually how many patients are being treated. But there is some old data, and if you project that to these days, you can estimate that somewhere between 100 and 200,000 people are receiving ECT a year. So it's not like ECT is something that's being used extensively and there's millions of people getting ECT. There's a very select group of patients that are getting it. There is also, in a number of studies, when I've looked at this topic before, there's a number of geographic differences. And some of this is gonna depend on some of these issues of things that might limit practice, such as laws, state laws, and things like that, that might limit that. But there is definitely less ECT per capita in the West. We had a study a number of years ago looking at Veterans Administration data, also indicating that there's disparities with African-American patients, and also these geographic issues that I'm mentioning. So other studies have also indicated that the number of hospitals conducting ECT has declined over the years, which to me is very concerning. And so there's less places that may offer ECT. But again, getting back to some of these numbers, it's hard to figure out exactly how many patients are being treated. If there's less hospitals doing ECT, and if that's true, is there actually less patients getting treated? And again, with all these varied healthcare systems, it's hard to exactly figure that out. Because ECT has largely become an outpatient procedure, the numbers could be the same, we just don't know. For example, in my career, it used to be 70% inpatient, 30% outpatient. Now it's completely flipped, where 60% to 80% of patients are being treated as outpatients. And things for all of us to be aware of in psychiatry is the barriers to access treatment. Like I mentioned, there's varied state laws on access to treatment. There's stigma that I constantly battle, and there's also concern about anti-psychiatry movements as well. So let's briefly touch base on COVID-19 and ECT, and just give you a sense of what I and a lot of my ECT colleagues experienced in those difficult times. In March of 2020, essentially many ECT practices were dramatically affected. And here's some of the key points here. That a lot of places, there are places that I was aware of that had actually ceased operating acutely during the COVID epidemic. But I would say many programs, most of us had to reduce our volume down to at least by at least 25 to 50%. At Michigan, I was only allowed to, initially during that first month or two of COVID, I was only able to do about 25% of the volume of ECT patients. And it was a very scary time for all of our patients and families that we were working with. And some of the critical things that were going on at the time that were major struggles included PPE issues. Here in the U.S. we had limited or no testing right away. And that was a big struggle initially. And we had no vaccines at the time. And we also had different risks to our colleagues in that setting with a lot of unknowns about the virus. So definitely we did a survey, University of Michigan's part of the National Network of Depression Centers. And we did a survey of our programs and we learned that there were fewer patients seen, of course. Our group also published an article about how catatonia patients, patients that were receiving maintenance ECT and some of the patients that Dr. Wachtell will highlight, some of these patients that we use ECT in a maintenance way also were relapsing, had re-hospitalizations. And it was just a very huge crisis for us. But, and also there was, in our group of depression centers that we surveyed, there was definitely, like I said, increased suicidal ideation and one reported suicide. And so it became apparent that from our group that we really needed to advocate that ECT is an essential treatment. It should not be withheld. It should not be considered elective. And I was facing a lot of that issue at Michigan where it's, it was considered not an emergent treatment. But as I mentioned, we had a lot of, we had a number of patients that did have some relapses. And so it was very concerning. So we did publish an article in the American Journal of Psychiatry highlighting that issue, that ECT is definitely an essential treatment. And so not only coming out of the COVID-19 pandemic, is that the case, but it needs to be considered that way if another pandemic ever were to happen again. So, but thankfully though, we did rebound by late 2020, got through all the testing. We had better testing, better vaccines and things improved over time. So let's shift from doing some overall background about ECT and some struggles and things that we faced in recent years, but also highlight some diagnostic types of patients that we wanna consider for ECT. So the geriatric depression patient has long been a type of patient that shows a good chance of having a nice response with ECT. And like a lot of studies, 60 to 70% remission type of, remission rate are possible with geriatric patients. And the PRIDE study, the prolonging remission in depressed elderly highlights this issue with over 240 patients with 62% remission. And that's also with using right unilateral ECT. Cognitive side effects, you know, are definitely a concern for patients and, but studies indicate that many mental status exams were stable during the ECT course with this particular study for sure, and that side effects tend to be transient. All right, so here's a disorder that's, you know, near and dear to me. And it's a type, it's one of these reasons that I do what I do. And when I was a resident, patients with this type of depression subtype are, they are the ones that respond probably the best and fastest. And quite commonly, it's miraculous is the way I would phrase it. And psychotic depression is very common in the elderly. And what I talk to residents and students about are the next few points, which is the common delusions. If you ask your students and residents, you know, if they know these three things, quite often they do not. But then once you clue them in, they can ask these patients and the, you know, ask patients about these things in the ER, on the inpatient unit, on consult floors, and they are gonna find a lot of these patients that are out there that have somatic preoccupations, they'll have delusions of poverty, they think they're going broke, and they also have severe nihilistic and guilty delusions. So it is one of those conditions that responds incredibly well to ECT. And what's really important too here with this article from Belgium is that it highlights just what I was mentioning, how fast this can be. So if you look at this diagram here, you'll see that even after two weeks, and in Belgium they tend to do ECT twice a week, not three times a week like we do here in the US, but even after the third week, which is literally only six treatments, they had a 60% percentage of their patients responding and separating out from those that just had unipolar depression without psychosis. So it can be dramatic and can be a very quick response. So patients, these patients are often very ill, they're under inpatient units, they're out there at home suffering, but when you see it, and if they're not doing well, not eating, physically not doing well, medically not doing well, ECT really should be considered earlier. What about maintenance ECT? We practice a lot of maintenance ECT these days, and more so than we did, say, 25 years ago. And like I mentioned before, ECT is largely an outpatient procedure these days, and what we're doing here is we're maintaining and we're continuing an ECT treatment schedule to prevent relapse, and if you don't do anything, say you just do a generic medication after ECT, the literature would suggest that you probably have about a 50% chance of relapse at six months to 12 months out. And then especially that early time, like right after you get them better, that first few weeks after completing an ECT acute course, there's a high chance of having relapse at that time. So some of the big take-home findings from years of research would indicate that you can prevent re-hospitalization and relapses if you do some form of maintenance, and that some of the definitions include using continuation ECT, which is usually the first six months after an index course, or maintenance ECT after you've been able to prevent that acute relapse and you're trying to maintain wellness. So in the real world, we're using medications plus ECT in combination, and so that combination can be quite powerful and very effective in maintaining patients and maintaining remission. So in recent years, there's been a really good meta-analysis looking at this issue of that combination being very, very potent for our patients. So what that looks like tends to be a brief taper of ECT is even common after the first index course, and we usually are thinking about a brief ECT taper, such as once a week, and then once every two weeks, and maybe four to eight treatments after an acute index course to prevent that rapid relapse, and that's very common, much more so than we ever did when I first became a ECT doc. And for those with a relapse history, we do use ECT longer haul, and may use it way beyond six months and sometimes years for some patients, and we have patients that do well with even a treatment every four to eight weeks in some situations, and they maintain wellness. Okay, and so let's briefly talk about ECT and schizophrenia. And ECT in patients with schizophrenia is not used that much, and there's many barriers to doing ECT in patients with schizophrenia in the U.S. especially, but in other countries, it's more available for those patients with psychosis. There's old data to support that the combination of medications, anti-psychotic medications with ECT is a powerful combination, as well as more modern data that indicate that clozapine plus ECT is a good combination. So in our country, in the U.S., if you are using ECT for schizophrenia, it tends to be in the context of someone with severe mood syndrome or definitely catatonia syndrome. And let's see here. And so in another, you know, patients with schizophrenia, if they do respond, maintenance ECT can be used as well. And so right now at Michigan, we have three or four patients that right now that we collaborate with our community mental health clinicians and treat them and keep their auditory hallucinations and their functioning much better. Briefly to discuss ECT and bipolar illness, ECT is very effective for bipolar depression as well. And the bottom point is that just like unipolar depression, there has been recent meta-analyses indicating that bipolar depression responds very well to ECT and you're talking about the same kind of number of remission with 50 to 60% type of remission. Patients that we also think about with bipolar illness that we may need to intervene acutely are patients with bipolar manic delirium. And I'm not sure how many people have actually seen manic delirium, but it is a very dramatic and serious and frightening type of episode for all that are involved. Patients and clinicians. These patients can slip into autonomic instability and have this agitated catatonia picture. Some of them may need to even be transferred to the medical floors. But it's as if they are just, there's an unrelenting manic syndrome and confusion and delirium that's happening. And sometimes the only way out of that may be ECT. So I could have chosen a number of neuropsychiatric emergencies to discuss, but I wanted to highlight another syndrome that we use ECT for, and that's neuroleptic malignant syndrome. We have quite a bit of experience with ECT and NMS. Over the years, we published an article of our experience over 20 years. And these cases may not pop up that often, but when they do, it can be very life-threatening and severe. NMS is like a version of lethal catatonia or malignant catatonia, and needs to be treated aggressively. And the way we tend to treat that is aggressive benzodiazepine treatment, acutely over three to five days. And if you're not getting much benefit, if you have the ability to do so, thinking about ECT is very important to try to get to as quickly as possible. Just recently, and things kind of come in little spurts, but just clinically recently, we've had one patient that we treated with ECT in the ICU who was intubated, had horrible NMS with exposure to aeropiprazole. And then another young lady that we're treating right now that wasn't in the ICU, but also very ill in reaction to haloperidol decanoate. So both are doing well at this time. So another issue that I'm gonna start, I'll start to wind down my talk here, but another clinical topic that I think, that I thought would be of use to discuss briefly at this clinical update is ECT versus ketamine. And so IV ketamine, intranasal ketamine, both are now available and people are using them quite widely right now in various clinics. They're popping up all over the place. And ketamine very may well have a nice role for patients with hard to treat depression. It has a nice speed of action. Patients can respond quite quickly. But the question is, one question that's out there is, is it as good as ECT? And what do we know right now? And so I will give you a little snippet of what we know right now. And what we do know is that with some studies that are out there in comparing these two treatments, a recent meta-analysis from this past year would indicate that ECT, quote unquote, suggests that ECT is superior. But you have this situation, if you dive into the details of the studies, you'll see that some of the studies that were included in this type of analysis indicate that the type of ECT that the patients were receiving was a short course perhaps, not a very long course, very few, less treatments than 12, like I mentioned, is a typical course. And so we have that issue to contend with. So what I worry about is that in some studies, you have to really read the methods and understand how are they doing the ECT? Is it actually really good ECT? Or is it a form of ECT that's been pitted against ketamine to show more of a change with ketamine? So the answer, I think, is still that ECT has an edge there for sure, but the edge may be actually wider than thought because of the way some of the ECT was done in some of these studies. And then, but what's coming up here and now, there's a new study with some preliminary data called the ELECT Study, ELECT-D Study, Electroconvulsive Therapy in Ketamine in Patients with Treatment-Resistant Depression. And this is a large multi-site PCORI-funded study. And so those results are just emerging now. So we'll have more data coming out perhaps this weekend and this year. We'll be learning more about what the study shows. And then this is just a brief summary of what I was talking about here today, is that there's predictors of response include older age, psychotic symptoms with depression, shorter duration of illness is always a helpful predictor of response for any treatment. And then severity of illness is important to consider. So the more severe the symptoms are, quite often that's a good predictor of response to ECT. It's not just for an end-stage resistant illness. It's something to remember. And like I said, I consider ECT early for severely ill patients, patients with severe suicidality, psychosis, and medical frailty. It's my contention and my belief that ECT still is underutilized at this time. And we all need to be aware that there's remaining stigma and legal restrictions and things that happen in various states that we need to be aware of, and that we all need to advocate that ECT is an important and essential treatment. And thank you. All right. Well, good morning. Thank you very much for inviting me here. I'm delighted to be here in San Francisco to speak with you today about ECT. And I'm really excited to be able to talk about ECT in a way that I think is really important and that we all need to be aware of. I'm delighted to be here in San Francisco to speak with you today about a topic that has been very near and dear to my heart over the past 15 years or so, in terms of the usage of ECT in child and adolescent psychiatry, particularly in the treatment of some of the most impaired youngsters that we work with in our field. I don't have any specific disclosures, and you're welcome to take photographs of any of the clinical slides, but you will also see some videos and some patient images that the families have all been very gracious in allowing me to share for professional purposes. But I'd appreciate it if you not make images of the patients' pictures themselves. Well, hopefully this will work. Okay. So during the session this morning, I tend to be a magnet for technological difficulties. Hopefully we won't have any. I'd like to review the relevance of ECT in child and adolescent psychiatry, going over some of the standard indications of electroconvulsive therapy in youth, both children and adolescents, and then review the expanding role of electroconvulsive therapy in autism spectrum disorders, as well as other forms of neurodevelopmental disability. Is it not loud enough? Speak up. Okay, sorry. I'm gonna go over some of the novel indication for repetitive self-injuries behavior in autism and the utility of ECT and its treatment, as well as reviewing many of the challenges to pediatric ECT. And this thing is not working. Okay. Okay, so why are we talking about ECT at all? Why do we talk about ECT in child and adolescent psychiatry? As we're coming up on nearly nine decades of the usage of convulsive therapy, and I emphasize convulsive therapy because it's really the convulsion that brings about the benefit in terms of healing from severe psychopathology as compared to the fashion in which it's elicited. We know over the course of the past almost 90 years that ECT has amazing benefit, rapid and robust benefit for a wide range of psychopathology from affective disorder to psychotic disorders, acute suicidality, catatonia, neuroleptic malignant syndrome, status epilepticus, as well as some movement disorders. We also know from the very beginning of convulsive therapy that convulsive therapy has offered relief for some of the most severely ill patients in our field. And this is just a reference to some of the first patients treated in 1934 Budapest by Meduna and some of his clinic notes describing patients who were really more or less completely incapacitated with inability to move, speak, eat, had been hospitalized over the course of years. Okay, but then looking at clinical results, you see that these patients in the very beginning experienced dramatic and amazing clinical benefit from convulsive therapy with patients, again, who were able after a period of significant incapacitation to do really basic things, things that we often take for granted in psychiatry, such as being able to talk, move, eat, and leave the hospital. ECT is most commonly used in the United States for major depression. And I just show you here some of the results of multi-site trials, both the CORE and CUC trials, which are multi-site trials conducted in the United States, looking at adults with major depression, so not children and not individuals with developmental disability. But you learn some very important things from these studies that are easily extractable to younger individuals. I've highlighted some of those very important findings. First of all, you see in the orange box just how ill these patients were. These are patients with very high HAMD scores. These are not the worried well. These are patients who most likely would have qualified for what might be considered an old-school diagnosis of melancholia with a positive dexamethasone suppression test. These are not people who are just frustrated by minor ups and downs of life. These are also patients who, if you look at remission rates, experience outstanding remission rates, far exceeding that of any drug on the market, in, if you look at the yellow box, a very short period of time. So, thinking that ECT in the United States is typically introduced on a thrice-weekly basis, you have an investment of two, three, maybe four weeks to get a patient who is severely psychiatrically ill well. It's a misnomer, of course, that major depression only afflicts adults and only afflicts individuals with developmental disabilities. I'm just going to show you a video here of one of my patients. Ah! I'm sad. Why? Why? So, I think that it should be obvious from the slide that this young man does have autism, developmental disability, but really that's not what jumps out at you at the slide. What jumps out to you at you is just the poignancy of his suffering and his experience of major depression that's not really dissimilar to an individual with more typical neurodevelopment. So, depression is a major problem in the United States in adolescents. This is a problem that's only gotten worse in recent years with the pandemic, both in terms of major depression incidences as well as increase in suicidal ideation and suicide attempts. It's estimated that about 20% of adolescents will have at least one bona fide episode of major depression before their 18th birthday. And unfortunately, even though there are best practice paradigms for the treatment of depression in adolescents, including psychotropics, largely SSRIs, as well as psychotherapeutic interventions surrounding mostly cognitive behavioral therapy, about 40% of individuals don't respond to those interventions. So it's great that 60% do, but 40% persist with treatment refractory depression. The American Academy of Child and Adolescent Psychiatry actually put forth practice parameters for the usage of ECT in adolescents in 2004. The parameters are due for an update. Important things to take away from the ACAP parameters are there criteria for ECT in a young person. First, as we can expect that you have to actually have an ECT responsive condition, such as an affective disorder, psychotic disorder, catatonia, neuroleptic malignant syndrome. ECT obviously doesn't help for substance abuse or for school dysfunction. So of course you need an ECT responsive condition and those are the same conditions that ECT works for in the adult patient population. You also need to have symptoms that are of sufficient severity to warrant looking at ECT, such as being acutely manic, psychotic, suicidal, not eating anymore, needing parenteral nutrition, or having unstable vital signs, for example. And then probably the most important criteria that many people overlook is that the American Academy of Child and Adolescent Psychiatry says that you should have two failed medication trials, just two, not 12, not 24, not everything that you can purchase in the United States and or import from Canada and Europe before you consider ECT as a next reasonable intervention for your patient who hasn't yet responded. Sadly, ECT is often delayed. This is definitely true in the adult patient population and even more so in pediatrics. This was a recent query regarding a young person who had had multiple suicide attempts already by the age of 14 and ECT was being considered after she'd had a near-fatal ingestion resulting in multiple cerebral infarcts as well as kidney failure, which fortunately had resolved, but just recently. And so it's kind of a sad situation because really clinically, the team had found themselves kind of up a creek without a paddle or with their paddles kind of wedged into the mud because previously they had a situation with a patient who was very appropriate for ECT and didn't have these additional potential medical problems. Now, with the time having elapsed and ECT not being considered in a more timely fashion, they had other things to consider before ECT could be safely considered for this patient. It's not uncommon at all. This is actually one of my favorite, even though it's a very sad case from years ago of a young person who had been in and out of hospitals for about 25% of his life with multiple suicide attempts and multiple failed medication trials, had been admitted after literally slitting open his abdomen and attempting to self-eviscerate, finally was sent to ECT, received right unilateral ECT. Electrode placement would be a completely different discussion, but for somebody that ill, bilateral ECT would have been the appropriate choice. Unfortunately, this patient then attempted to murder his mother and slit his own throat, at which point the question was raised as to whether bilateral ECT would be okay. Okay, so what do we actually know in general outside of clinical antidotes about the efficacy of ECT in young people? And we actually know a lot. And in recent years, since the turn of the century, there's been more and more information available. The first kind of large study is from Ray and Walter, prior to the turn of the century, looking at the usage of ECT over the five decades prior. And you see some really amazing percentages in terms of efficacy for major psychiatric disorders with patients responding most prominently with major depression, mania, and catatonia, but also some pretty okay numbers for schizophrenia. If you read through many of the studies that were included in the overview by Ray and Walter, you'll also come across some studies from France and from Bellevue in New York that included individuals who likely today would have been diagnosed with autism or other forms of neurodevelopmental disability. We also learned very early on that ECT is safe in young people, with the most common side effect being a headache, which is the same as it is in adults. Okay, well, that was the last century, or the last millennia, but there's other literature that's constantly being published on this topic. This is a more recent study looking at patients in the first 20 years of this century, where you see similar response for patients treated with major affective, psychotic, or catatonic illness, again, with a mean of 9.3 ECT, so an investment of three weeks of clinical time to get somebody well, and patients on the clinical global impression scales, either 77% of them reported as much or very much improved. Really impressive numbers. This is a very recent study from the University of Utah, where they followed a number of youth, including some pre-pubertal children, so you see here an age range between 10 and 18, notice how ill these patients were. Some of these patients were included before the DSM-5 came out, so GAFs were still used, and these patients had very low GAFs. These are patients functioning at the very, very low end of the psychiatric spectrum. Again, average number of ECT, 10.5, so about three weeks of investment in time, and markedly positive response on clinical global impression scales across depression, mania, mood disorders, and catatonia. This is a very recent study from the group at Harvard, comparing efficacy of ECT and also cognitive effects in adolescents, transitional-age youth, so from 18 to 25, and young adults, demonstrating similar response in terms of symptom reduction, and also, importantly, pointing out that ECT led to a 1.1 reduction in the MOCA, so very limited impact, if any at all, on cognitive functioning, particularly when you separate out the cognitive issues that you might expect from somebody with psychopathology requiring ECT. Most importantly, age was not a predictor of response or of MOCA scores. Okay, so why are these numbers important? Well, first of all, these numbers are important because they're pretty awesome. They're a lot better than any medication out there on the market, and they've been consistent over several decades, so pushing nine decades of efficacy is kind of cool. They also offer solid hope, and in working in child psychiatry, they're able to offer solid hope for children and families, because remember, you're not just treating the child in a vacuum. The family is also gonna be significantly negatively impacted by severe mental illness, but offering them solid hope for people who haven't had a chance to get better yet, and when you think about the long-term consequences of treatment-resistant depression, for example, obviously there are consequences for adults, but I think that those consequences are really amplified in a child or an adolescent who's still going through multiple stages of development on multiple levels. We know that adolescents with treatment-resistant depression have a higher risk of recurrence in adulthood, higher suicide rates, lower overall academic achievement, more social impairment in family and relationship problems, so setting them up for chaos throughout the lifetime. I also like to think about a perspective of developmental windows and important developmental tasks that you only get kind of one chance to do in childhood and adolescence, and if those windows are closed because of severe psychiatric illness, you might not have a chance to recapture those. We talk about individuals with autism, and I'm going to move into autism and neurodevelopmental disability next. It's also important to remember that having neurodevelopmental disability comes with what I kind of think about as extra costs. So, first of all, we know that individuals with autism have a higher risk of psychopathology across the board. I'm going to speak largely about autism, but remember, in neurodevelopmental disability at large, we've seen a huge increase in recognition of ECT-responsive conditions in various genetic syndromes, Down syndrome, Velocotier facial syndrome, Phelan-McDermott syndrome, and those should also be kept in mind, particularly working with adult patients, many of whom present as young adults with catatonia or psychosis and may actually get that genetic diagnosis only when they first present with a neuropsychiatric disturbance. Okay, so individuals with neurodevelopmental disability already have a huge number of challenges, communication challenges, learning challenges, medical comorbidities, and unfortunately, often insufficient or unequal access to resources and services. These individuals definitely represent a population where health equity has yet to be achieved. So the real new ECT frontier over the past decade and a half or so, two decades or so, I would say, has been the relationship between catatonia and autism spectrum disorders. So catatonia dates back to 1874. This is Carl Kaubaum and his original manuscript where he described the motor, vocal, and behavioral symptoms of the unique catatonia diagnosis. What does that have to do with autism? It actually has a lot to do with autism because we have learned that approximately 12 to 20% of individuals with autism will present with catatonia. That was first demonstrated in 2000 by the British. Subsequent studies from Sweden, University of Michigan in the USA, and then the UK again. Importantly, most of these patients who presented with catatonia in the context of autism were older adolescents or younger adults. So really a topic that's relevant, obviously, for child psychiatry, but also for adult psychiatry, particularly for patients with higher-functioning autism who might not already have been segregated out into mental health care particularly designated for neurodevelopmental disabilities and could present in a general psychiatric practice. We see a wide range of symptoms and symptom presentation in catatonia and autism spectrum disorders. And you see here in the various stills what I like to call the two sides to the catatonia coin, one being the obvious presentation of immobility, stupor, staring, unresponsiveness, but then also that flip side of catatonia in terms of the purposeless agitation that I think you can see represented even in the stills with self-injurious behavior or wild agitation caught in photo as well as some of the significantly devastating results of that type of behavior. It's important to keep in mind also when you're considering catatonia in autism spectrum disorder that the catatonia diagnosis itself in the DSM has 12 symptoms, you only need to have three of those. There are no required one symptoms, there's no required grouping of symptoms. And with autism, you can often have what we call like diagnostic overshadowing. Many things that present as catatonic symptoms sometimes get chalked up to other in autism, such as food refusal. People kind of think, well, individuals with developmental disabilities may always have had issues like that. So maybe it's because they always prefer to have green things rather than purple things. Or maybe they're having behavioral agitation because their reinforcers are no longer working or their behavioral protocol is no longer working or they have a neurodegenerative condition superimposed on their developmental disability. Reasonable questions to ask, but they oftentimes cloud over the obvious catatonia staring at you. And we look a lot at this, again, this spectrum of catatonia in autism spectrum disorders, where you see in the lower right hand what you usually expect from catatonia in terms of that immobility, not moving, the patient has stripped naked. But then this wild purposeless agitation and you can only imagine the potential results of that. And when we talk about self-injurious behavior in autism spectrum disorders, the band-aid is probably the ultimate of euphemisms because self-injurious behavior can lead to truly devastating and severe bodily injury and really a global psychosocial incapacitation where the patient is more or less physically restrained, both mechanically, chemically, and then with additional kind of caretakers on top of them just to prevent ongoing tissue injury. And sadly, while we do have a lot of psychotropic interventions, behavioral therapies available for this patient population, they don't always work. When purposeless agitation is recognized within the context of catatonic agitation in autism spectrum disorders, ECT works quickly and it works well. If you look at the graph here, you will see on the y-axis behaviors per hour. I will point out this is also, if you look kind of on the vertical at the end where equipment was removed, this is a patient who at the beginning would largely have been immobilized in protective equipment from head to toe, still having huge amounts of repetitive self-injurious behavior. Then you see the introduction of ECT. You see ECT one, two, three, behaviors drop to the x-axis. I am going to show you a couple of videos that decide to play on their own. This is one of my very recent cases. This is, we've termed this grass rubbing echopraxia. I've seen a lot of echopraxia before, but never of rubbing the grass. Interestingly, if you ask this gentleman how he became ill, he's very well now, as you'll see in the videos. He tells you that he crouched in the garden and kissed stone. I'm gonna show you an example of catatonic agitation. This is an Israeli-American family. The child is kind of yelling in a mishmash of Hebrew and English, talking largely like nonsense after cursing the coronavirus. That's it. Stop the fighting. Stop all this shit. Okay, now I'm gonna show you his baseline after ECT. Hi. Hi, hi, hi. Hi. Hey, hey, hi, hi. Well, this patient definitely has a very unique infectious joy about him. But you certainly see what we call like the night and day difference. So we've gone from crouching in the garden, rubbing the grass. This patient had also stopped eating. He'd also stopped pooping. Parents had to provide him with like suppositories and all sorts of other interventions to even get him to void. And now he is back to his baseline. He does still have autism. He does still have intellectual disability. ECT does not cure that. I offer no cure for autism or intellectual disability, but ECT can rapidly and safely clear very serious conditions that occur, unfortunately, more readily in autism than in the neurotypical population. Okay, okay, so I'm gonna finish up just talking about some of the obstacles to pediatric ECT. So I'm actually somebody who kind of likes ice and snow and obstacles, particularly on ski trails, but I'd really prefer them not to be present in clinical practice. And there are many when you're dealing with pediatric ECT that deserve our attention and our work to continue to rectify. First of all, nobody wishes more than me that ECT was like amoxicillin and you could go twice a day for 10 days and then be done forever. Unfortunately, it's not. Like many things in medicine, ECT is a treatment. It's not a cure. Many patients require high frequency of ECT as well as maintenance ECT in order to remain well. This is not dissimilar to the usage of insulin and diabetes, dialysis for renal failure. And I always like to remind people that I've been wearing contact lenses for over four decades now, and my vision is still just as bad as it was when I was initially fitted with them. I wish that wasn't the case, but oh well, what can we do? Sadly, there are a lot of limitations to the access of ECT in youth in the United States. This is something that's been left up to the state's discretion, and many states have arbitrary and nonsensical restrictions and age limits for access to ECT, further creating situations of health inequity whereby if you live in one of these states and your child needs ECT, he or she can access that if you have the financial resources to go to another state and access ECT. I think that health inequities have certainly been emphasized during the pandemic as something that we strive to overcome. And if you think about ECT over the long range, there's been ethical books on the ethics of ECT, one by Addison and Fink that went through ethical principles really that came to light, I guess, after World War II, determining that ECT as a practice meets all of those ethical principles of medicine with the exception of that of justice in that it's not universally available to everybody with appropriate clinical need. ECT, unfortunately, always invites resistance. I've spent many years as the little Sam-I-Am character wandering around, you know, presenting this to people like, well, why don't you try it? It's really not so bad. We could try it this way or that way. And I think usually the response has been after a long period of time, it's been, well, you know what, Dr. Wachtell, if you'll just shut up, we'll give you a try. And then they realize that it works. And then we're cooking with gas. We think we're all familiar with media damage associated with ECT. Adult patients are victims to this. Our adolescent patients surely are. My children typically get their information from Siri, Alexa, and other things on the internet. And that's not gonna provide you with the most accurate information, certainly not with any type of scientific information that your patients are able to hang their hats on. Interestingly, we do know that ultimately amongst professionals, education works. I think that's part of the reason why we are here today. This was a study by, again, that group, Ray and Walter, who did that overview, the 50-year overview of ECT in the last part of the last century, showing that people's opinions can be changed. And the way to effectuate that is through education. Of course, in order to be educated, your mind needs to be open. And this is a favorite proverb of mine from the Yoruba people of Nigeria, that a mind is like a parachute. It is useless unless open. To not know is bad, but to not want to know, and in the case of ECT, that sometimes means just being mired down in stigma, is far worse. And I'd just like to close by stating that ECT can make a profound difference in a young person's life, and don't miss that opportunity for your patients and their families. And thank you so much. Thank you. So thank you to both of our speakers, we'll now take questions both in person and online while alternate. So if anyone has an in-person question, you can walk up to the two microphones. You want to come up to the one on the microphone? Please walk up to the microphones and ask them and we'll go one by one. Thank you for the wonderful presentation. My name is Mohamed Selim, I'm from Egypt, I'm a child and adolescent psychiatrist. My question to Dr. Wachtel, is there any controlled or uncontrolled trials specifically that try to address this issue of effectiveness of ECT in the catatonia in autistic children and adolescents specifically in autistic children? Was your question whether there's a controlled trial? Controlled or uncontrolled, like any prospective trial to specifically work on adolescents with catatonia and autism? No, so it's a great question. There's not currently any type of clinical trial for ECT for catatonia and autism. Many of these patients, because of the devastation of their acute clinical situation, wouldn't really be appropriate to be kind of randomized to like A versus B. I think the barriers to those types of studies in a vulnerable patient population, vulnerable not only because they're children, but also because they're individuals with developmental disability, has always made like a formal research protocol a very daunting project. So the information that we have has largely been comprised of case reports, case series, as well as retrospective studies that facilities have done looking at groups of individuals with autism, and now also starting with other neurodevelopmental disorders, I feel in McDermid Down Syndrome, it's become kind of a hot topic in the world of Down Syndrome, where many of those individuals present as young adults with Down Syndrome Disintegrative Disorder, which can often be catatonia. But the information that we have would be either case report, case series, or retrospective studies. Some of which have been compilations from multiple facilities to try and increase like the N and the impact. So you think it's not feasible right now to design such a study? I think that the challenge of pushing something like that through an investigational review board is huge. And I also think that the patients, typically the patients that I worked with, like you see the clinical devastation. It would be very difficult, for example, if you have like, I've had malignant catatonics in the ICU, who only like modern medicine is like keeping them alive. And we know that they have like malignant catatonia, and they need to go to ECT because they might otherwise expire. Or patients whose repetitive self-injurious behavior has gotten so bad that they've had a bilateral retinal detachment, and they have to have emergency eye surgery to repair that. Otherwise they're going to lose their vision. So it becomes very difficult then to imagine a situation where like you wouldn't, knowing that the experience that ECT works, where you would deny that to those types of patients. Thank you. Mustafa, stay in. So hold on, we need to, we're alternating with the ones that are coming in from live stream video. Okay. Go ahead. The question is, whether or not, what's the, have there been any studies of concurrent use of ketamine for depression and ECT? Not that I'm aware of at this time. I'm not aware of one. Mustafa, are you going to say that? No. Yeah, not that I'm aware of right now. So there's been historically some interest in like, can I combine ketamine sedation with ECT, which we do use ketamine quite a bit for short seizures. But data in that area is lacking and, or, you know, the actual benefit of the combining IV ketamine in, you know, sedation is kind of lacking. I think there are some interesting concepts. Right now, you know, could you interleave, you know, both treatments and perhaps use both to, you know, switch one over to the other. So for example, if you have somebody who's dependent on ECT, does ketamine have a role for that? So I think there's a lot of exciting questions to ask about this. In fact, right now I have a patient that I've treated for a long, long time with maintenance ECT that just keeps her suicidality quiet, keeps her well, keeps her out of the hospital. But getting ECT on a regular basis is something that she would like to try to not do. And so we're actually trying to swap out or taper off ECT while we're trying to do the IV ketamine. So there's all kinds of permutations and things that are possible. But data so far is lacking on that. So Mustafa Hussain from University of Texas Southwestern Medical School. So I have more of a comment. I'd like to congratulate the panel, especially Dan and Elizabeth. This is a wonderful basic ECT program that I've seen. The other thing is amazing to see these people around and congratulations. Ludum, Household, that's wonderful. Let me quote from the Bible of psychiatry, Kaplan and Sadek, ECT is the most effective treatment available in psychiatry today. And it's regretful how many obstacles that we have. It's regretful that it's not being used. Just 100 to 200K patients a year? And how many of people are dying with suicide and other reasons? So really, you guys are our ambassadors to promote the use of ECT in that respect. My last statement is, I'm glad to see, Dan, that you talked about ketamine and others. And this is just plug-in. Look, the stigma of ECT, we will not be able to get rid of it, the media and others. And there are other treatments which are coming forward. TMS is one of them. But the most critical and if there is ever going to be anything to get even close to ECT will be magnetic seizure therapy, all right? There's a large study going on from Canada, UT Southwestern, San Diego, CREST study. Just hold on and the results should be coming out soon. Thank you so much. »» So there's another question about, I'm going to combine two questions. So is a second opinion required for a child to get ECT? And then can children with autism spectrum disorder and seizures benefit from ECT? »» So those are actually both great questions. So first of all, in terms of referring a young person for ECT, and this would also probably apply to even somebody over age 18 with a neurodevelopmental disability where they may have cognitive impairment and not necessarily able to provide fully informed consent. It varies from state to state, and it would also vary from facility to facility. Where I work, for example, in the Hopkins Medical System, you have to have two additional board certified child psychiatrists who are uninvolved in the child's care, evaluate the child, review the history and concur that ECT would be appropriate and potentially beneficial. Some states require three. Some states, as Mustafa was indicating in terms of barriers, have many other barriers like lawyers have to confer to concur and you need to pay for various legal procedures to get ECT authorized. But the general answer is yes. Usually at least one other board certified psychiatrist, if not two, would independently evaluate the patient and then agree that ECT is appropriate. In terms of the seizure question, so that's a really awesome question on multiple levels. Many children with autism do have concurrent seizures. We see seizures start oftentimes in small children with autism, so like in the toddler age, but then there's like a second bump in incidents in like late adolescence, and many of our patients who present with catatonia or severe psychopathology would be late adolescence. So first of all, if somebody with autism does have a seizure disorder, they can absolutely also be treated with ECT. It becomes a question of managing their anticonvulsants, which usually means that the anticonvulsant is held the night before and then the morning of ECT. And you ask the ECT team if they could possibly be treated earlier in the day rather than later in the day so they can get their anticonvulsant when they return from ECT like at 9 or 10 in the morning rather than later in the afternoon. ECT also in terms of seizures, as we know with ECT, each time you receive ECT it increases your seizure threshold. This is why ECT is used in status and in some countries is used for seizure management where they don't have access to some of the very expensive and unusual anticonvulsants that some people require. So potentially ECT in a child with autism and seizures might even increase their seizure threshold and make them less likely to have other seizures. But you can see the opposite. And we have had some patients with autism who develop tardive seizures or seizures that appear outside of the course of ECT, which is something that happens very, very rarely in typically developing adults. But that does sometimes happen in autism and warrants monitoring. Question from the second mic. Thank you. I really want to echo what everyone else has said. I really appreciate this talk. I'm Arthur Levam from University of Louisville in Louisville, Kentucky. We're really the only provider of ECT in a 100-mile radius in the city, in a medium-sized city. One question we've come up with recently, and I know there is some literature on this, is post-COVID psychosis and post-COVID catatonia. I think this has been a more recognized topic or disease recently after the pandemic. We've had a lot of difficulty in the inpatient you're treating post-COVID psychosis and catatonia doesn't seem to respond as well to medications from our anecdotal experience. Is there any data out there for ECT in this patient populations or populations and what data do you think it has any benefit? You may have you you may have more experience than than most right at this point because it all those are going to be primarily case case studies and so forth and there really is not a large you know data set that I know of treating you know the post COVID syndromes. You know like I mentioned before you know Michigan's part of the National Network of Depression Centers and we've surveyed each other trying to you know find my colleagues at a you know 20 some academic centers you know who has treated COVID you know for specific neuropsychiatric syndromes and it's just not it's pretty rare but you know you you know so I appreciate you you know manage those things and I think you know in a lot of medical conditions the neuropsychiatric syndromes emerge whether it's you know the latest you know we didn't talk about NMDAR catatonia problems and things like that so there's numerous types of neuropsychiatric syndromes that that may you know that ECT may well have a role that we need to consider. Thank you. We have another question. Why is ECT not done more frequently even earlier in chronic psychosis considering its its efficacy and low incidence of adverse effects? Is there a point where ECT in those cases will be too late or ineffective? So yeah for you know for schizophrenia or for psychotic illness like I mentioned before it's just it's a ECTs are rarely used treatment for for that patient population. Again a lot of barriers right there's legal issues patients have with schizophrenia often have minimal insight to their condition and so if it's a chronic psychosis and they're having you know you know debilitating hallucinations well they're clearly not going to consent for that so you need to have a system in place where you can actually get guardianship and whether the emergent you know family member or emergency guardianship so you can you know you can help that patient but but here in the US it's definitely harder to to treat those patients with severe psychosis and the other part of that question is it too late? Yeah I think you know again there's there you know just like with depression too that you know the longer an illness is going on the episode the longer the episode the more medications you failed the tougher it is to respond to anything. With respect to schizophrenia you know cases that I've been able to treat that may have more of debilitating kind of chronic auditory hallucinations psychosis that's really struck that patients really struggle with and if they even if they have partial insight and the meds are helping a little bit it does take it does take you know quite a bit of collaboration with a family guardianship the community mental health system that you're working with to make to make that happen so it's doable but but you really need to have a decent system in place to make that happen for those patients and the bulk of patients like I mentioned that have psychosis are going to be patients that are gonna be on inpatient service with severe suicidality or catatonia problems and mood syndromes. I think it's also important to keep in mind though that a major depression is the most common indication for ECT in the United States but that's not the case in all countries so I believe that actually in Southeast Asia particularly in India I think that psychosis and schizophrenia is the primary indication for ECT so there are many places where ECT is used much more regularly for psychotic illness. In terms of children adolescents there's actually a group out of Barcelona, Flamanique and colleagues who have for years looked at ECT compared with atypical antipsychotics for adolescents with schizophrenia spectrum disorders and have published some really interesting studies not only demonstrating similar efficacy but also demonstrating on both patient and parent satisfaction with ECT and with given a choice between pursuit of further atypical or typical antipsychotics and electroconvulsive therapy. Thank you again for organizing this symposium because ECT as we know one of the most effective treatment to psychiatry there is no question. Well the question is that sometimes we can find review one of them I would like to refer to was published in year 2015 quite recently review about special populations pregnancy and in that review authors concluded that ECT must be the last resort for patient who are pregnant because of adverse effect that well more severe than we expected according to that review. What's your collective vision collective wisdom treating patients with severe depression mental disorders who are pregnant? Thank you. I mean over decades of work you know we've treated a number of pregnant patients and and essentially they've all done done well and if you look at all of the you know case literature and small studies you know the data would suggest that it can be done it's you know very safely and very effectively for patients during pregnancy. There's always you know there's always you know strategies and things you have to do and and you know working with high-risk OB team you know different monitoring that you might have to do during pregnancy but you can definitely do it quite safely and I and over the years I've done that that what I will say though is you know most likely with you know with medications being found to be also you know reasonably safe during pregnancy that I'm likely seeing less of these severe cases where where there's more use of other medications during pregnancy whether it's antidepressants or even atypicals and things like that that might help stabilize mood or treat psychosis or depression. So at least in our system I've overall seen less patients during pregnancy for ECT but but again it's very effective when needed. Yeah there's some good literature reports on that I think I another issue that arises particularly if it's later in pregnancy is that some practitioners would prefer in like the third trimester to actually go ahead and intubate the patient to reduce the risk of aspiration particularly later in pregnancy as you have much more volume but no in general I mean the literature is like very promising for ECT in pregnancy and right there are a lot of medications that can be safely used like during the course of pregnancy but I think the verdict might still be out like in acute mania or psychosis in terms of comparing ECT versus pumping a patient full of like potentially highly toxic medications during a pregnancy as compared to having been like on their SSRI throughout the pregnancy and hopefully remain stable. So what is the youngest age you would consider for possible ECT or is it just dependent on symptoms and level of impairment? Yeah we were just we just brought this up you know some of us before the meeting we were just talking about this so the way I phrase it is that you know and that's what you know what concerns me about state laws and things that we need to be all aware of is that psychiatric illness neuropsychiatric syndromes you know those things don't really care how old you are you know period and so whether it's you know whether it's an NMDAR encephalitis type picture where there's severe catonia happening you may need to intervene there's cases in the literature of treating it toddlers little ones as young as you know two to three two to four range when when severe symptoms are there and you need to you need to do something or the patient you know is going to die so so I think those are that's sort of the lowest age range and we you know at a big academic Medical Center we've had you know those types of cases before as well it's you know they're very complex cases and you have to be you know very careful you have to you know educate family about what you're doing and everybody has to be on board where the risk and benefits because some of these cases may may or may not respond to the ECT but quite often it can be done you know very safely and there's cases of not only treating encephalitis type pictures with catonia as a syndrome that's associated with it but things like intractable seizure problems and things like that ECT does have some transient potent anticonvulsant properties to it and so that's that's part of the reason why that would be tried in that patient group I think in general it's it's it's unlikely that in like a toddler for example or like a pre-pubertal child like elementary age that you're going to see like intractable psychosis or you know severe suicidality even catatonia we tend to see that in autism and somewhat older patients but some of the some of the conditions that dr. Mexner mentions for example and particularly with this rapid increase in like amdar and all the encephalitic pictures that we've seen in children those really don't care like how old you are and they afflict younger children just as regularly as older children and then status would be another situation where your choices would be an anesthesia induced coma or ECT and there may be an element of like family preference but then that comes to having that conversation with the family in terms of options to pursue whether for status or for encephalitic pictures which typically patients who are referred to ECT for amdar other types of encephalitis would have already had first-line plex IVIG chemotherapeutic agents sometimes in like tandem so they're typically looking at ECT after those agents have failed and oftentimes the presentation the overall neuropsychiatric presentation of those children who are sometimes quite young is really dire and so ECT is totally reasonable to consider if you can give a young person his or her life back I Rick Troutner with Bay Psychiatric Associates here in the Bay Area we have an interventional service where we have ECT TMS and ketamine and we're often in the position of trying to decide which patient gets what I'm very curious first of all that TMS hasn't even been mentioned yet today and how you think about that first of all I guess that's question number one why is that not even on the map here but the second is how you would think about differentiating among those treatments for various patients you know aside from the clear cases of psychosis or catatonia but how would assuming you had those options available how would you make those decisions thank you right I mean you know definitely the focus you know today is ECT and we we you know I also do some TMS as well and so you know a lot of it has to do with invasiveness right so you have if you look if you sort of stage invasiveness of neuromodulation or the ketamine treatments you know ECT is going to be a little bit more invasive because you're inducing seizure there's more to do there you know they're you know all these things that you have to do and there's and there's you know potential memory or cognitive side effects that you have to manage and and contend with but you know so so a lot of a lot of times what I think of right now anyway with with TMS or ketamine is that those are would be more in your earlier stages of resistance is the way I would kind of phrase it you know and so you have this dichotomy of resistant depression and then you have you have this others other arena where you have to act faster right and so ECT definitely has a role when you got it when you got to go fast and you need and you need to help that patient now acutely emergently they're in the hospital of course ECT may be a good a good strategy but for for the outpatient situation you know I think I would I would phrase it this way that that you know ketamine and TMS tend to be in my my mind more of a early resistant type of strategy or patients that you know that you can't tolerate medications and things like that for for TMS and and I'm and I'm okay with that because a lot of times you know a lot of time if you stage their treatments you know what you don't you know to me what you don't want to do is just say you know here you know here's another SSRI or do you know you're not doing anything that's different or has a different mechanism and and they're and they're languishing and so I what I tend to do is I worry about the patients that may be early in resistance but yet they disappear and they tried you know try TMS or ketamine and then they go away and they never have been staged appropriately or just had that discussion about ECT and so what I usually talk to patients about it's like you know you know try ketamine or try TMS if that's your preference I don't I don't mind but don't go away for a year or two and disappear and not get back to me because I've staged this for you I've mentioned all these things to your outpatient doc that you should be thinking about and I my preference would be that you get back to ECT sooner if you're still languishing and not doing very well so I don't have a set like med failure number and things like that but but that's those are some general ideas that I would have so is there any new data or old on the efficacy of ECT in personalities disorders especially borderline personality disorder so you know in general you know there are some studies that would say you know for depression and in patients with significant access to personality disorder pathology that the numbers might be you know definitely lower than you know the 60 to 80 percent that we were talking about for typical unipolar depression for remission and so some of the in what that means is that some studies might older data might suggest 25% or 50% so it's it's in that range in my mind and you have to kind of pick your spots with that and and so when I'm evaluating patients that that have comorbid trauma issues or comorbid personality you know borderline pathology I have to be upfront with them and I will I will tell them I you do have a significant depression so I'm actually searching for their depression syndrome to be worse than it is you know in the chronic state associated with their with their personality you know pathology but you know so not only is it's worse but it's also is there a sense that there's some episode to it where you know you know they were much better they were less suicidal they had much better functioning they were working more and so I'm always kind of searching for that that episode and where that where that where those boundaries might be when I'm talking to a patient with access to pathology so we can be appropriately you know frank with them and and let them know that you know to whatever extent this is a severe exacerbation of depression we have a shot at that but you're you know but given the fact that you have all these other issues and chronic suicidality and and this diagnosis of borderline personality and all these all these other things your chance of remission may not be as good as 60 80 percent but may actually be closer to 50 percent or even potentially less so those are kinds of discussions that I have with with patients with that type of pathology. I think the question is relevant not only to personality disorders but also other comorbid conditions like substance abuse or even like eating disorders where traditionally you wouldn't think of ECT as particularly being a treatment for that disorder itself but sometimes within those disorders there's a subset of individuals with very severe additional ECT responsive psychopathology who may do very well with ECT we've recently seen that for example in like the anorexia world where there's a difference for example between an anorexic patient whose symptomology is largely driven by I don't know like a plastic surgery addiction or desire to wear children's clothing versus somebody with anorexia who may actually have really profound major depression with like true bonafide suicidality or other psychotic symptoms some of those patients can be a little scary to treat I think the lowest weight we've had has been an adult at about 65 pounds so anesthesia always like raises their eyes a little bit at that but so you never want to really like throw out patient groups even if of course like ECT is not going to fix like the core symptoms of a borderline personality disorder or like substance abuse or even someone with an eating disorder they probably still are going to have other issues but it can often address like concomitant psychopathology that can be really prevalent in you know again a wide range of diagnoses that aren't often like the first ones mentioned in terms of patients as far as ECT candidates yes I'm Gautam from India thank you very much for the all panelists for organizing such an excellent program on ECT sir you have mentioned the cost effectiveness I just really ask a basic question from the very background of the ECTs and all when we are students we used to do the unmodified ECTs but when I consider right now in the modified ECT it is a not a very inexpensive because there are lots of we have to engage the anesthesiologist anesthetist and also the setup is different so it is a expensive a bit what do you think the unmodified versus modified there is a basic questions right now also in India Mental Health Care Act 2017 they are very much strict to only modified ECTs but my question is really we are doing modified ECT for the we are scared about the human rights people or is there is definitely there are some biological reasons for shifting totally from unmodified to modified ECT so just for the audience so unmodified means that you're not actively without anesthesia and if you do have anesthesia it might be a light sedative or something or but but typically no muscle relaxant type of agent right and so the question is you know exactly so can you repeat like summarize that your statement and question again one more time so what is the what was the overarching question then what's that the cost like kind of cost of it yeah I mean in various countries you know unmodified ECTs you know still may be you know provided because it's an emergent you know strategy and so ethically I think we would you know ethically you would say that that you know you'd prefer to have modified ECT with with full anesthesia and full muscle relaxation it's going to be safer in many ways less less risk of all kinds of physical complications bone fractures what-have-you other things but but but it's a it's an ethical dilemma you know do you withhold something that needs to happen because that person is catatonic and psychotic and going to die versus versus you know having availability of some you know more of a medical setting for the modified so the the cost-effectiveness that we're that I was referring to is you know it has a lot to do with the overall arching of how much how much does it cost to have a good you know a quality of life you know and those types of things so not not the not the exact specific ECT treatment cost itself day-to-day which can be a barrier for for people in other countries yeah I think you bring also some myself but the comparative study with the RTMS repetitive transmagnetic stimulations with the city too if you compare to the ECT with the RTMS you have mentioned ketamine comparative study with ECT efficacy just to add on to what is what the question you asked about like unmodified ECT I think you do bring up like a really valid point in terms of health equity and also kind of the ethics of providing like a treatment to individuals who might not have the luxury for example of living in the United States or living in another place where fully like modified ECT and like a regular surgery center with oxygenation and kind of the best of the best is available I actually several years ago was at a World Psychiatric Association meeting in Prague where it was another individual from India who got into kind of an argument or a debate with people about that stating that he had patients from very poor areas who couldn't afford to pay for anesthesia but they wanted to have ECT regardless because they knew that their lives were not very good without ECT and so that really brought up a lot of ethical questions you know they were willing to accept the fact that they were going to have it without anesthesia and it might not be as comfortable and as pleasant but why should they be denied that just because some people you know in wealthier Western countries felt that it wasn't appropriate so it's a it's a really good question from a health equity perspective. Thank you.

Electroconvulsive Therapy

ECT

Dr. Daniel Maxner

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